MU Clinical Quality Measures: Alignment Across Quality InitiativesFact Sheet

Provided By:The National Learning Consortium (NLC)

Developed By:Health Information Technology Research Center (HITRC)

The material in this document was developed by Regional Extension Center staff in the performance of technical support and EHR implementation. The information in this document is not intended to serve as legal advice nor should it substitute for legal counsel. Users are encouraged to seek additional detailed technical guidance to supplement the information contained within. The REC staff developed these materials based on the technology and law that were in place at the time this document was developed. Therefore, advances in technology and/or changes to the law subsequent to that date may not have been incorporated into this material.

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NATIONAL LEARNING CONSORTIUM The National Learning Consortium (NLC) is a virtual and evolving body of knowledge and resources designed to support healthcare providers and health IT professionals working towards the implementation, adoption and meaningful use of certified EHR systems.

The NLC represents the collective EHR implementation experiences and knowledge gained directly from the field of ONC’s outreach programs (REC, Beacon, State HIE) and through the Health Information Technology Research Center (HITRC) Communities of Practice (CoPs).

The following resource can be used in support of the EHR Implementation Lifecycle. It is recommended by “boots-on-the-ground” professionals for use by others who have made the commitment to implement or upgrade to certified EHR systems.

EHR Implementation Lifecycle

DESCRIPTION & INSTRUCTIONS The clinical quality measures (CQMs) included in the EHR Incentive Program align with measures used in other Federal quality initiatives. The same CQMs are also aggregated to measure and improve quality of providers, health plans, and state-funded medical programs like Medicaid and Children’s Health Insurance Program (CHIP). This factsheet describes how providers’ efforts to measure and improve quality using EHRs aligns with the following quality initiatives:

Provider-Level Initiatives

Physician Quality Reporting System (PQRS)http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html?redirect=/pqrs

Accountable Care Organizations (ACO)http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality_Measures_Standards.html

Million Hearts Campaignhttp://millionhearts.hhs.gov/index.html

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State-Level Initiatives

Children’s Health Insurance Program Reauthorization Acthttp://www.ahrq.gov/policymakers/chipra/index.html

Health Plan-Level Initiatives

Medicare Advantagehttp://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/ReportingRequirements.html

For further information on CQMs and Meaningful Use, please visit: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/ehrincentiveprograms/

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TABLE OF CONTENTS

1 Meaningful Use Clinical Quality Measure Alignment by Measure.........................................................1

2 Meaningful Use Clinical Quality Measure Alignment by Number of Initiatives.......................................4

3 Reporting of Clinical Quality Measures..................................................................................................7

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1 Meaningful Use Clinical Quality Measure Alignment by MeasureThe following table provides a summary of the various initiatives to which 2014 Meaningful Use CQMs also apply It also provides a column with the total number of initiatives (inclusive of Meaningful Use) to which each measure applies.

Stage 2/2014 Clinical Quality Measure Comparison for 2013Meaningful Use Stage 2/2104 Measure

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Mea

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CHIP

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ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range (NQF# TBD) (CMS179v1) 1

ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (NQF# 0108) (CMS136v2)

2

Adult Weight Screening and Follow-up (NQF# 0421) (CMS69v1) 3

Anti-Depressant Medication Management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment (NQF# 0105) (CMS128v1)

2

Appropriate Testing for Children with Pharyngitis (NQF# 0002) (CMSv146v1) 3

Appropriate Treatment for Children with Upper Respiratory Infection (URI) (NQF# 0069) (CMS154v1) 2

Bipolar Disorder and Major Depression: Appraisal For Alcohol or Chemical Substance Use (NQF# 0110) (CMS169v1) 1

Breast Cancer Screening (NQF# 0031) (CMS125v1) 4

Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery (NQF# 0565) (CMS133v1) 2

Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures (NQF# 0564 2

Cervical Cancer Screening (NQF# 0032) (CMS124v1) 2

Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment (NQF# 1365) (CMS177v1) 1

Childhood Immunization Status (NQF# 0038) (CMS117v1) 3

1 http://www.cms.gov/apps/ama/license.asp?file=/PQRS/downloads/2013_PQRS_MeasuresList_ImplementationGuide_12192012.zip2 http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures-Specs.pdf3 http://millionhearts.hhs.gov/docs/Field_Engagement_Opportunities.pdf4 http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-002.pdf

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Stage 2/2014 Clinical Quality Measure Comparison for 2013Children Who Have Dental Decay or Cavities (NQF# 1419) (CMS74v2) 1

Chlamydia Screening for Women (NQF# 0033) (CMS153V1) 3

Closing the referral loop: receipt of specialist report (NQF# 1335) (CMS75v1) 1

Colorectal Cancer Screening (NQF# 0034) (CMS130v1) 4

Controlling High Blood Pressure (NQF #0018) (CMS165v1) 5

Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) (NQF# 0070) (CMS145v1)

2

Dementia: Cognitive Assessment (NQF# TBD) (CMS149v1) 2

Depression Remission at 12 months (NQF# 0710) (CMS159v1) 2

Depression Utilization of the PHQ-9 Tool (NQF# 0712) (CMS160v1) 1

Diabetes: HbA1c Poor Control (NQF# 0059) (CMS122v1) 4

Diabetes: Eye Exam (NQF# 0055) (CMS131v1) 3

Diabetes: Foot Exam (NQF# 0056) (CMS123v1) 2

Diabetes: LDL Management & Control (NQF# 0064) (CMS163v1) 5

Diabetes: Urine Screening (NQF# 0062) (CMS134v1) 3

Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care (NQF# 0089) (CMS142V1) 2

Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy (NQF# 0088) (CMS167v1)

2

Documentation of Current Medications in the Medical Record (NQF# 0419) (CMS68v2) 2

Functional Status Assessment for Complex Chronic Conditions (NQF# TBD) (CMS90v2) 1

Functional Status Assessment for Hip Replacement (NQF# TBD) (CMS56v1) 1

Functional Status Assessment for Knee Replacement (NQF# TBD) (CMS66v1) 1

Heart Failure (HF) : Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) (NQF# 0081) (CMS135v1)

2

Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (NQF# 0083) (CMS144v1) 3

Hemoglobin A1c Test for Pediatric Patients (NQF# 0060) (CMS148v1) 2

HIV/AIDS: Medical Visit (NQF# 0403) (CMS62v1) 1

HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis (NQF# 0405) (CMS52v1) 2

HIV/AIDS: RNA control for patients with HIV (NQF# 0407) (CMS77v1) 2

Hypertension: Improvement in blood pressure (NQF# TBD) (CMS65v2) 2

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement (NQF# 0004) 2

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Stage 2/2014 Clinical Quality Measure Comparison for 2013(CMS137v1)Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control (NQF# 0075) (CMS182v1) 4

Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic (NQF# 0068) (CMS164v1) 4

Low Back Pain: Use of Imaging Studies (NQF# 0052) (CMS166v2) 2

Major Depressive Disorder (MDD): Suicide Risk Assessment (NQF# 0104) (CMS161v1) 2

Maternal Depression Screening (NQF #1401) (CMS82v1) 1

Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer (NQF# 0387) (CMS140v1)

2

Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients (NQF# 0385) (CMS141v2) 2

Oncology: Medical and Radiation - Pain Intensity Quantified (NQF# 0384) (CMS157v1) 2

Pneumonia Vaccination Status for Older Adults (NQF# 0043) (CMS127v1) 3

Pregnant Women that had HBsAg testing (NQF# 0608) (CMS158v1) 1

Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment (NQF# 0028) (CMS138v1) 4

Preventive Care and Screening Measure Pair: b) Tobacco Cessation Intervention (NQF# 0028) (CMS138v1) 4

Preventive Care and Screening: Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# TBD) (CMS61v2) 2

Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old (NQF# 0041) (CMS147v1) 3

Preventive Care and Screening: Risk-Stratified Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# TBD) (CMS64v2)

2

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (NQF# 0418) (CMS2v2) 3

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (NQF# TBD) (CMS22v1) 3

Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists (NQF# 1419) (CMS74v2) 1

Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation (NQF# 0086) (CMS143v1) 2

Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients (NQF# 0389) (CMS129v2) 2

Screening for Future Fall Risk (NQF# 0101) (CMS139v1) 3

Use of Appropriate Medications for Asthma (NQF# 0036) (CMS126v1) 2

Use of High-Risk Medications in the Elderly (NQF# 0022) (CMS156v1) 3

Use of Imaging Studies for Low Back Pain (NQF# 0052) (CMS166v2) 2

Weight Assessment and Counseling for Children and Adolescents (NQF# 0024) (CMS155v1) 3

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2 Meaningful Use Clinical Quality Measure Alignment by Number of Initiatives

Many clinical quality measures apply to more than one quality initiative. This table groups the 2014 Meaningful Use CQMs by the number of quality programs to which they apply.

Alignment by Number of InitiativesNumber of Programs Meaningful Use Stage 2/2014 CQM

Measures that apply to 5 (five) quality reporting initiatives

Controlling High Blood Pressure (NQF #0018) (CMS165v1)Diabetes: LDL Management & Control (NQF# 0064) (CMS163v1)

Measures that apply to 4 (four) quality reporting initiatives

Breast Cancer Screening (NQF# 0031) (CMS125v1)Colorectal Cancer Screening (NQF# 0034) (CMS130v1)Diabetes: HbA1c Poor Control (NQF# 0059) (CMS122v1)Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control (NQF# 0075) (CMS182v1)Ischemic Vascular Disease (IVD): Use of Aspirin or another Antithrombotic (NQF# 0068) (CMS164v1)Preventive Care and Screening Measure Pair: a) Tobacco Use Assessment (NQF# 0028) (CMS138v1)Preventive Care and Screening Measure Pair: b) Tobacco Cessation Intervention (NQF# 0028) (CMS138v1)Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old (NQF# 0041) (CMS147v1)

Measures that apply to 3 (three) quality reporting Initiatives

Adult Weight Screening and Follow-up (NQF# 0421) (CMS69v1)Appropriate Testing for Children with Pharyngitis (NQF# 0002) (CMSv146v1)Childhood Immunization Status (NQF# 0038) (CMS117v1)Chlamydia Screening for Women (NQF# 0033) (CMS153V1)Diabetes: Eye Exam (NQF# 0055) (CMS131v1)Diabetes: Urine Screening (NQF# 0062) (CMS134v1)Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (NQF# 0083) (CMS144v1)Pneumonia Vaccination Status for Older Adults (NQF# 0043) (CMS127v1)Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (NQF# 0418) (CMS2v2)Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (NQF# TBD) (CMS22v1)Screening for Future Fall Risk (NQF# 0101) (CMS139v1)Use of High-Risk Medications in the Elderly (NQF# 0022) (CMS156v1)Weight Assessment and Counseling for Children and Adolescents (NQF# 0024) (CMS155v1)

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Alignment by Number of InitiativesMeasures that apply to 2 (two) quality

reporting initiativesADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (NQF# 0108) (CMS136v2)Anti-Depressant Medication Management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment (NQF# 0105) (CMS128v1)Appropriate Treatment for Children with Upper Respiratory Infection (URI) (NQF# 0069) (CMS154v1)Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery (NQF# 0565) (CMS133v1)Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures (NQF# 0564) ) (CMS132V1)Cervical Cancer Screening (NQF# 0032) (CMS124v1)Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) (NQF# 0070) (CMS145v1)Dementia: Cognitive Assessment (NQF# TBD) (CMS149v1)Depression Remission at 12 months (NQF# 0710) (CMS159v1)Diabetes: Foot Exam (NQF# 0056) (CMS123v1)Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care (NQF# 0089) (CMS142V1)Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy (NQF# 0088) (CMS167v1)Documentation of Current Medications in the Medical Record (NQF# 0419) (CMS68v2)Heart Failure (HF) : Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) (NQF# 0081) (CMS135v1)Hemoglobin A1c Test for Pediatric Patients (NQF# 0060) (CMS148v1)HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP) Prophylaxis (NQF# 0405) (CMS52v1)HIV/AIDS: RNA control for patients with HIV (NQF# 0407) (CMS77v1)Hypertension: Improvement in blood pressure (NQF# TBD) (CMS65v2)Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: (a) Initiation, (b) Engagement (NQF# 0004) (CMS137v1)Low Back Pain: Use of Imaging Studies (NQF# 0052) (CMS166v2)Major Depressive Disorder (MDD): Suicide Risk Assessment (NQF# 0104) (CMS161v1)Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer (NQF# 0387) ) (CMS140v1)Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients (NQF# 0385) (CMS141v2)Oncology: Medical and Radiation - Pain Intensity Quantified (NQF# 0384) (CMS157v1)

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Alignment by Number of InitiativesPreventive Care and Screening: Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# TBD) (CMS61v2)Preventive Care and Screening: Risk-Stratified Cholesterol-Fasting Low Density Lipoprotein (LDL-C) Test Performed (NQF# TBD) (CMS64v2)Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation (NQF# 0086) (CMS143v1)Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients (NQF# 0389) ) (CMS129v2)Use of Appropriate Medications for Asthma (NQF# 0036) (CMS126v1)Use of Imaging Studies for Low Back Pain (NQF# 0052) (CMS166v2)

Measures that apply to 1 (one) quality reporting initiatives (EHR Incentive

Program)

ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range (NQF# TBD) (CMS179v1)Bipolar Disorder and Major Depression: Appraisal For Alcohol or Chemical Substance Use (NQF# 0110) (CMS169v1)Child and Adolescent Major Depressive Disorder: Suicide Risk Assessment (NQF# 1365) (CMS177v1)Children Who Have Dental Decay or Cavities (NQF# 1419) (CMS74v2)Closing the referral loop: receipt of specialist report (NQF# TBD) (CMS75v1)Depression Utilization of the PHQ-9 Tool (NQF# 0712) (CMS160v1)Functional Status Assessment for Complex Chronic Conditions (NQF# TBD) (CMS90v2)Functional Status Assessment for Hip Replacement (NQF# TBD) (CMS56v1)Functional Status Assessment for Knee Replacement (NQF# TBD) (CMS66v1)HIV/AIDS: Medical Visit (NQF# 0403) (CMS62v1)Maternal Depression Screening (NQF #1401) (CMS82v1)Pregnant Women that had HBsAg testing (NQF# 0608) (CMS158v1)Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists (NQF# 1419) (CMS74v2)

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3 Reporting of Clinical Quality MeasuresTo assess compliance with and monitor the progress of the varied initiatives, most programs require that the CQM outcomes be reported. In many initiatives, information may be collected and reported by various entities using combinations of different mechanisms, such as claims or surveys. The table below focuses on the role of the provider in reporting.

The table below indicates which providers or organizations are responsible for reporting CQM information, the source of CQM data, the mechanism by which providers report CQM information, and the initiative related purpose of such reporting. Although all clinical quality measurement initiatives aim to improve healthcare quality and outcomes, there are often specific incentives or goals associated with specific initiatives. Providers who are reporting CQMs for multiple initiatives will now – or soon be – making their measures ‘count’ multiple times, by measuring and reporting them only once

Provider Reporting of Clinical Quality MeasuresQuality Initiative Who Reports CQMs Source of Data Provider Reporting Mechanism Purpose of ReportingEHR Incentive Program Eligible providers Electronic Medical Record Attestation or Group Practice

Reporting Option (GPRO)Determine eligibility for EHR Incentive

Physician Quality Reporting System

Eligible Medicare physicians Medical records Group Practice Reporting Option (GPRO)

Determine eligibility for PQRS incentive payment

Accountable Care Organizations5 Medicare approved ACOs Medical records, surveys, & claims

Group Practice Reporting Option (GPRO)

Determine eligibility to share in savings

Million Hearts Campaign Provider volunteers Provider determined Optional6 Prevent cardiac related deathsChildren’s Health Insurance Program

Medicaid & CHIP agencies Claims N/A - State reported Monitor and improve quality for Medicaid & CHIP beneficiaries

Medicare Advantage Part C Medicare Health Plans Medical records, surveys, & claims

Determined by health plan where applicable

Provide publicly available quality ratings for Medicare Advantage Plans

5 The ACO program reports on survey, claims, and medical record based measures. Individual ACOs are directly responsible only for reporting on medical record based measures using GPRO.6 Million Hearts is a voluntary program, including whether or not a provider reports on the associated quality measures.

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